Ensures accurate, timely maintenance, and synchronization of critical Provider data on all Provider databases, and systems such as Claims, Data Management, and Authorization/Referral systems. Accesses and utilizes multiple software applications. Applies business rules and knowledge of Provider contract language, pricing and reimbursement methodologies to each database/system to validate Provider information in all systems. Communicates with internal and external customers by phone and email to clarify data and follow-up on issues, working under timeline, accuracy and production targets. Requires the ability to manage a large amount of complex information, communicate clearly, and draw sound conclusions. Performs simple credentialing activities including performing primary source verifications and entering the initial data of potential Providers into the Provider database and credentialing system(s). Collaborate with the Provider Data Specialists and provide clear instructions to correct data issues. Ensure correct reimbursement and Provider data is housed in all downstream systems.
• Resolves Provider data discrepancies related to claims processing, including contract reimbursement rates within the allotted timeframe. • Manage daily follow up of Provider data correction requests and issues to ensure databases are current and accurate. • Ensures and maintains accurate data within the Provider Claims and Authorization databases • Contacts Providers to verify all credentialing, claims, and billing information • Ensures appropriate tax documentation is obtained and imaged for Provider files • Corrects reimbursement issues within claims payment system • Develops, maintains, and processes reimbursement terms ensuring correct claims payment and downstream processing. • Reviews Provider contract language and identifies when a contract is out of compliance. Process Provider contracts, run reports, and respond to inquiries regarding contract compliance issues; image and index contracts and return images to network subcontractors; conduct quality assurance activities to ensure image quality and completion of image activities. Queries primary sources and OIG, as applicable, to verify Provider credentials and qualifications
• Professionally and concisely communicate in writing and by phone, information and/or instructions for updating and correcting databases • Resolves 1099 and W9 discrepancies • Assist in the development and update of protocols and procedures • Coordinates with Claims and other departments on Provider database related issues • Resolves daily error reports which include data rejected from claims system including data rejecting from all downstream systems • Perform other duties as assigned • Regular and reliable attendance is required
Education & Experience
• High School Diploma or GED • 2 years of varied responsible experience with computer database programs • 2 years of Health Care experience such as claims, provider data or authorization or referral processing • Experience with Microsoft Suite (including, but not limited to, Word, Excel and Outlook)
• 1+ years of Health care claims resolution experience • Experience using a Provider Data Management System, Claims System, or Authorization/Referral system
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